SIT DOWN, STAND UP, BEND OVER

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant ProgramAssistant Professor, Department of Orthopaedics & Sports MedicineUSF Health, Morsani College of Medicine

A Review of the

Musculoskeletal

Physical Examination

History

Questions must include:• Onset

• Mechanism of injury

• Quality of symptoms

• Persistence of symptoms

• Previous injuries

• Treatment to date

You cannot overemphasize the importance of a thorough

and detailed history. In most cases if you ask the

appropriate questions you will have a very good idea of

the diagnosis before you ever examine the patient.

• ADL’s

• Work activities

• Precipitating factors

• Alleviating factors

• Mechanical symptoms

• Training routines

Physical Examination

A typical routine might be:• Inspection

• Palpation

• R.O.M.

• Strength

• Stability

• Special tests

You should strive to perform a detailed and systematic

physical examination that follows a similar pattern each

time you evaluate a patient. Knowing appropriate anatomy

is paramount to properly evaluating your patients.

Don’t forget:• Joint above/below

• Neurological

• Vascular

• Referred pain

Anatomy - Vertebral

Column

• 7 Cervical

vertebrae

• 12 Thoracic

vertebrae

• 5 Lumbar

vertebrae

• Sacrum

Anatomy

• Vertebral column– Anterior Segment - weight bearing

• Vertebral Bodies

• Intervertebral Disc

– Posterior Segment - regulates motion and protects spinal cord and nerve roots

• Facet joints

• Pedicles

• Neural Foramina

• Spinous processes

• Muscular insertions

• Spinal Cord and nerve roots

Thoracic – horizontal, allowing rotation,

side-bending

Lumbar – vertical, allowing flexion/extension

Anatomy

Ligaments• Prevent extremes of

movement

• Anterior and

Posterior

Longitudinal

Ligaments

• Posterior Ligament

narrows near sacrum

Muscles• Superficial

– Erector Spinae

• Deep

– Multifidis

– Interspinalis

– Intertransversarii

• Psoas

• Iliacus

• Abdominals

Anatomy - Nerves

An unfortunate patient is diagnosed with having

a lateral disc herniation at the C56 and L45 levels.

• Which of the following dermatomes would you

expect to be affected?

a) C5 and L4

b) C6 and L5

c) C5 and L5

d) C6 and L4

Anatomy – Nerve Roots

Anatomy - Nerves

Cervical SpinePalpation• Spinous process

• Paravertebral muscles

Range of Motion• Flexion

• Extension

• Rotation

• Lateral bending

Sensation• C2

• C3

• C4

• C5

• C6

• C7

• C8

• T1

Strength• C5

• C6

• C7

• C8

• T1

Reflexes• C5

• C6

• C7

Special Tests• Spurling’s

• Valsalva

• Compression/Distraction

• Vertebral Artery Test

Motor

Reflexes

Sensory

Cervical

Lumbar SpinePalpation• Spinous process

• Paravertebral muscles

Range of Motion• Flexion

• Extension

• Rotation

• Lateral bending

Sensation• L1

• L2

• L3

• L4

• L5

• S1

• S2-5

Strength• T12 – L3

• L2 – L4

• L4

• L5

• S1

Reflexes• L4

• S1

• Babinski

Special Tests• Straight leg raise

• Gaenslen’s

• Pelvic ‘rock’

• One-leg hyperextension

• Patrick (Fabere)

• Hoover’s

• Kernig/ Brudzinkski

Examination Of Patient With Low Back Pain

Shoulder Anatomy

Shoulder AnatomyLigaments

Shoulder AnatomyMuscles

Shoulder Exam• Inspection

– Atrophy

– Scapular dyskinesis

• ROM

– Active vs. passive

• Strength

– Rotator cuff

• Special Tests

– Impingement

– Stability

©2003-2007 Dr. Lintner, MD. eMedWebs, Inc.® - TOS - Houston TX

Scapular Dyskinesis

Atrophy

ShoulderPalpation• Bones

– SC

– Clavicle

– AC

– Scapula

– Coracoid process

– Greater tubercle humerus

– Biceps groove

ShoulderRange of Motion - active/passive

• Shoulder shrug – symmetry

• Forward flexion – 180 degrees

• Extension – 50 degrees

• Abduction – 180 degrees

• Adduction – 50 degrees

• Internal rotation – 90 degrees

• External rotation – 90 degrees

Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30:136–151

Range of Motion

Shoulder

Strength

• Shoulder shrug - CN XI

• Forward flexion

• Abduction

• Internal/external rotation

Strength

• Supraspinatus – abduction

• Infraspinatus – external rotation

• Teres Minor – external rotation

• Subscapularis – internal rotation

Murrell GAC and Walton J. Clinical diagnosis of rotator cuff tears. The Lancet, 357 (2001): 769-770.

Empty can – supraspinatus External rotation – infraspinatus

Hawkins impingement test Apprehension test

Rotator Cuff Exam

Special Tests

Neer’s test• Supraspinatus

Impingement

Stability Exam• Sulcus sign

• Apprehension test

• Apprehension-relocation test

• Anterior/posterior drawer test

Generalized Laxity

SLAP Exam(Superior Labrum Anterior Posterior)

• Compression rotation test

• Obrien’s test

• Biceps tension test (speed test)

Nerve InjuriesSuprascapular Nerve

Nerve InjuriesLong Thoracic Nerve

Elbow

• Carrying Angle

• Surface Anatomy

– Medial epicondyle

– Lateral epicondyle

– Olecranon

– Ulnar groove

– Radial head

Elbow

• Special Tests

– Varus/Valgus Stress

– Lateral Epicondylitis

– Medial Epicondylitis

– Tinel's Sign

• ROM

– Flexion, extension,

pronation, supination

• Manual muscle

strength

Wrist, Hand and Fingers

• Surface Anatomy

– Ulnar Styloid

– Scaphoid

– Pisiform

– Hook of hamate

– MCP joints

– IP joints

Wrist, Hand and Fingers• Special Tests

– Pinch Grip

– Finkelstein Test

– Phalen's

– Tinel

– Allen's

• ROM

– Flexion, extension,

pronation, supination,

radial/ulnar deviation,

excursion (MC rotation)

• Manual Muscle Tests

Hip

• Injuries to hip & pelvis are often

frustrating

– Evaluation is difficult

• May involve variety of soft tissues and bones

• May be acute, sub-acute or chronic

• Large differential diagnosis

– Understand mechanism, natural history &

physical findings

– Accurate diagnosis is essential

Hip• Inspection

• Palpation

• ROM (passive/active)– Lumbar spine

– Hip• Flexion – 120

• Extension – 10

• Abduction – 40

• Adduction – 30

• Internal rotation – 50

• External rotation – 35

– Knee

• Strength

– Flexors

– Extensors

– Abductors

– Adductors

– Hamstrings

– Quadriceps

Hip

• Neurovascular– Sensation

– Pulses

– DTR

• Specific tests– Trendelenburg

– Ober test

– Patrick’s/Fabere test

– Gaenslen's test

– Compression/Distraction

– Hernia/testicular

Knee Anatomy

Knee• Key factors in making

diagnosis

– Mechanism of injury

– Onset of swelling

– Ability to bear weight

– Mechanical symptoms

– Instability

– Pre-existing conditions

• Inspection

– Lacerations/Contusions

– Alignment/Deformity

– Effusion/Hemarthrosis

– Gait

• Palpation

– Joint line pain

• Meniscus tear

– Palpable defects

• Quadriceps tendon,

Patella ligament, Patella

fracture

• Alignment

Knee

• ROM– Knee (0 - 140)

• Strength– Quadriceps

• Straight leg raise

• Extensor lag

– Hamstrings

• Neurovascular

Knee

Physical Examination

• Special tests– Meniscus

• Joint line pain

• Squat

• Steinmann

• McMurray

• Apley

• Thessaly

• Hip

Differential Diagnosis

Acute hemarthrosis– Peripheral meniscus tear

– ACL/PCL tear

– Dislocation

• Patella, knee

– Fractures

– Bleeding disorders

• Coumadin

• PVNS

vs.

Prepatellar Bursitis

Physical Examination

LigamentsInjured Ligament Key Test Secondary Test

ACL Lachman Pivot Shift

MCL Valgus laxity at 30 Valgus laxity at 0

PCL Posterior drawer at 90 Posterior sag at 90

LCL Varus laxity at 30 Varus laxity at 0

Posterolateral corner ER at 30 Posterior drawer at 30

Ligament Injuries - ACLExamination

– Hemarthrosis

– Contralateral side

– Anterior drawer

– Lachman

– Pivot Shift

• Difficult to reproduce

• Must be relaxed

Ligament Injuries – MCL

Examination

– Pain to palpation

– Little or no

effusion/hemarthrosis

– Valgus instability at

30 (@ 0 ACL)

– In child consider

growth plate injury

Ligament Injuries – PCL

Examination

– Hemarthrosis

– Posterior drawer

– Posterior sag

– Quadriceps active test

Extensor Mechanism Injuries• Commonly misdiagnosed

• Anatomy

– Quadriceps muscle quadriceps tendon patella patella tendon

• History– Patella tendon

• Younger patient

• Athletics

– Quadriceps tendon• Older patient

• Systemic disease

– Vigorous eccentric quadriceps contraction

– Unable to straighten leg

– Fluoroquinolones (Cipro, Levaquin, etc.)

Extensor Mechanism Injuries

• Examination

– Palpable defect

– Unable to do straight leg raise

• Extensor lag

– Hemarthrosis

• Imaging

– Radiographs

• Patella alta

• Peds – sleeve fracture, tibial tubercle avulsion

– MRI/Ultrasound

Extensor Mechanism Injuries

Anterior Knee Pain

• Multifaceted

– Mal-alignment

– Weakness (VMO, hip extensors)

– Decreased flexibility (quad, calf

– Neuromuscular adaptations (increased

reflex arc, decreased response times)

– Generalized joint laxity

Q – angle Pronated Foot

PFPS – Exam

• Observe and palpate tracking

through active flexion and

extension

• Crepitus most noticeable with

active motion

• Patellar compression may

increase pain

• Translate patella laterally in

extension and attempt to flex

knee

• Assess general laxity

Popliteal Cyst – Exam• Between

semimembranosus and medial head gastrocnemius

• Most visible and palpable with the knee extended (standing)

• Palpate for size, consistency, and tenderness

• Examine the knee for signs of derangement (i.e. meniscal tears)

Popliteal Cyst –

Differential Diagnosis

• Deep vein thrombosis (ultrasound)

• Exertional compartment syndrome

(compartment pressure measurement)

• Inflammatory arthritis (serologic tests)

• Medial gastrocnemius strain (H & P)

• Soft-tissue tumor (MRI)

• Superficial phlebitis (H & P, –US)

Ankle Anatomy

Ankle Anatomy

Ankle• Inspection

– Pronation, pes planus

• Palpation

– Medial malleolus, lateral malleolus, navicular, 5th

metatarsal

– ATFL, deltoid, peroneal, posterior tibialis

• ROM / Strength

– Dorsiflexion, plantarflexion, inversion, eversion, subtalar motion

With inversion sprains

the foot is forcefully

inverted or occurs when

the foot comes into

contact w/ uneven

surfaces

Inversion Injuries

Ankle Stability Tests• Anterior drawer test

– Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily

– A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point

Talar tilt test• Performed to determine

extent of inversion or eversion injuries

• With foot at 90 degrees, calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments

• If the calcaneus is everted, the deltoid ligament is tested

Eversion Ankle Sprains

• Etiology

– Bony protection and

ligament strength

decreases likelihood of

injury

– Eversion force resulting

in damage to deltoid and

possibly fx of the fibula

– Deltoid can also be

impinged and contused

with inversion sprains Represent <5-10% of all ankle sprains

Syndesmosis Sprain‘High Ankle’ Sprain

• Mechanism of injury– External rotation force

– ‘Turf’ sports• Player prone and force applied to back of leg

• Fixed, planted foot with cutting or blow to leg

• Examination– Pain at distal syndesmosis

– Squeeze test

– Pain at syndesmosis with external rotation of foot

– Athlete walks on toes

• Diagnostic Studies– X-ray

– Stress test

– MRI

4 Ligaments

1

3

2

4

Ottawa Foot & Ankle RulesAn ankle x-ray is required only if there is any pain in malleolar zone and

any of these findings:•Bone tenderness at A

•Bone tenderness at B

•Inability to weight bear both immediately and in the ED

A foot x-ray is required if there is any pain in the midfoot zone and any of

these findings:•Bone tenderness at C

•Bone tenderness at D

•Inability to weight bear both immediately and in the ED

Questions?

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant ProgramAssistant Professor, Department of Orthopaedics & Sports MedicineUSF Health, Morsani College of MedicineLcollins@Health.usf.edu

A Review of the Musculoskeletal

Physical Examination

Thank You